Pharmaceutical combination and its use for treating synucleinopathies

ABSTRACT

The present invention describes the combination of a 6-propylamino-4,5,6,7-tetrahydro-1,3- benzothiazole-2-amine or of a pharmaceutically acceptable salt or solvate thereof with fluoxetine or a pharmaceutically acceptable salt or solvate thereof, for use for treating a synucleinopathy such as Parkinson&#39;s disease, Lewy body disease, mutations in the glucocerebrosidase gene, or multiple system atrophy.

RELATED APPLICATIONS

This application claims the benefit of United States Provisional PatentApplication

Serial No. 62/485,082, filed Apr. 13, 2017, the disclosure of which isincorporated herein by reference in its entirety.

FIELD OF THE INVENTION

The present invention pertains to the field of the treatment ofsynucleinopathies, i.e. of neurodegenerative disorders of the humancentral nervous system, and in particular of the treatment of neurotoxicprocesses due to the alpha-synuclein oligomerization and aggregation.

OBJECT OF THE INVENTION

The present invention concerns a pharmaceutical combination comprising6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or apharmaceutically acceptable salt or solvate thereof and fluoxetine or apharmaceutically acceptable salt thereof, including fixed-dosecombinations, and its use for the treatment of synucleinopathies, inparticular the central nervous system neurotoxic effects ofalpha-synuclein in a human subject showing an abnormal plasmaexosomal/total alpha-synuclein ratio in blood.

DEFINITIONS

-   “CNS”: Central Nervous System.-   “IR”: Immediate Release of the active ingredient from a composition.-   “ER”: Extended Release of the active ingredient from a composition.-   “GI”: Gastro-Intestinal.-   “AE(s)”: Adverse Effect(s).-   “TTS”: Transdermal Therapeutic System.-   “LBD”: Lewy Body Dementia.-   “AD”: Alzheimer's Disease.-   “SNCA gene”: Synuclein-alpha or alpha-synuclein gene.-   “Synucleinopathy”: A disease characterized by the abnormal    accumulation, processing and propagation of alpha-synuclein    (α-synuclein) in the brain. Namely, α-synuclein deposits in the    central, peripheral, and autonomic nervous system. Synucleinopathies    (also called α-synucleinopathies) are neurodegenerative diseases    which include, but are not limited to Parkinson's disease, Lewy body    dementia LBD) or dementia with Lewy bodies (DLB), Alzheimer's    disease, the Lewy body variant of AD, multiple system atrophy,    neurodegeneration with brain iron accumulation, and parkinsonian    disorders associated with glucocerebrosidase (GBA) mutations.-   “GBA”: Mutations in the glucocerebrosidase gene.-   “MSA”: Multiple System Atrophy.-   “PD”: Parkinson's Disease.-   “6-Propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine”: A    chiral chemical compound that is available as racemate, chemically    (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, as    (R)-stereoisomer, chemically    (R)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    (“dexpramipexole”, INN), and as (S)-stereoisomer, chemically    (S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    (“pramipexole”, INN). These three chemical entities are basic    substances that may be isolated each as an acid addition salt and    solvate thereof. Pramipexole dihydrochloride monohydrate is also    known with its USAN “pramipexole hydrochloride”. As used herein,    “6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine” is a    general term that, unless otherwise specified, designates a member    selected from the group consisting of pramipexole, the racemate, and    a pramipexole/dexpramipexole mixture.-   “(R)/(S)-mixture”: This term designates a dexpramipexole/pramipexole    physical mixture used as an active ingredient according to the    present invention.-   “(S)-enantiomer”: This term, as used herein with reference to    6-propylamino-4,5,6,7 -tetrahydro-1,3-benzothiazole-2-amine doses    (daily or per unit form) designates the (S)-stereoisomer, included    in said doses that, in said 6-propylamino-4,5,6,7-tetrahydro-1,3    -benzothiazole-2-amine, is primarily responsible for its    dopaminergic action. More specifically, S-enantiomer is herein used    to designate the S-stereoisomer that is present in the racemate or    pharmaceutically acceptable salt thereof, and similarly, to    designate the pramipexole or pharmaceutically acceptable salt    thereof that is present, as (S)-constituent, in a (R)/(S)-mixture,    in order to distinguish it from pramipexole used alone.-   The terms    “6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine”,    “(R)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine”,    “dexpramipexole”, “pramipexole”,    “(S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine”,    “(S)-enantiomer”, “racemate” and “(R)/(S)-mixture” include the free    bases and pharmaceutically acceptable salts thereof (unless    otherwise specified); and the relative doses (daily or per unit    form) are given in equivalents of pramipexole dihydrochloride    monohydrate.-   “Effective daily dose of pramipexole” or “effective daily dose of    (S)-enantiomer”: An effective pediatric or adult daily pramipexole    or pharmaceutically acceptable salts and solvates thereof dose    equivalent to at least the pramipexole dihydrochloride monohydrate    approved daily dose for the treatment of PD.-   “Effective pramipexole amount (or dose) per unit form” or “effective    amount (or dose) per unit form of (S)-enantiomer”: An amount per    unit form of pramipexole or pharmaceutically acceptable salt or    solvate thereof that is equivalent to at least a pramipexole    dihydrochloride monohydrate amount per unit form approved for the    treatment of PD. More specifically said amount per unit form is    equivalent to from 0.125 mg to 20 mg of pramipexole dihydrochloride    monohydrate. As noted above and as used herein, “pramipexole” and    “(S)-enantiomer” refer to the same chemical entity, but the term    “(S)-enantiomer” is generally used when describing the composition    of the racemate and of (R)/(S)-mixtures.

BACKGROUND OF THE INVENTION

Alpha-synuclein, a protein composed of 140 amino acids encoded by theSNCA (Synuclein-Alpha) gene, is abundantly expressed in the human brainand to a lesser extent in various other organs. In brain,alpha-synuclein(hereafter also referred to as simply “synuclein”) ismainly found in neuronal terminals, especially in the cortex,hippocampus, substantia nigra and cerebellum, where it contributes tothe regulation of neurotransmitter release, and passes into theperipheral blood stream (Marques and Outeiro, 2012), in part packagedwithin exosomal vesicles originating from the CNS (Shi et al, 2014).

Under normal circumstances, this soluble protein appears to form astably folded tetramer that resists aggregation. But, in certainpathological conditions, for unknown reasons, the alpha-synucleinmisfolds, oligomerizes and aggregates (with the formation of fibrils).Somewhere along this aberrant pathway, toxic synuclein species arebelieved to be formed which also pass into the peripheral (systemic)circulation, carried within exosomes.

Aberrant alpha-synuclein oligomerization and aggregation are thought tobe the cause of synucleinopathies, notably PD, LBD, parkinsoniandisorders associated with glucocerebrosidase (GBA) mutations, MSA,multiple system atrophy, some forms of Alzheimer's disease, and severalother disorders, which are collectively referred to as“synucleinopathies”. Alpha-synuclein is a ubiquitous protein that isespecially abundant in the brain and has been postulated to play acentral role in the pathogenesis of Parkinson's disease (PD),Alzheimer's disease, and other neurodegenerative disorders (Kim et al.2004).

Synucleinopathies are generally defined as a group of neurodegenerativedisorders characterized in part by the intracellular accumulation ofabnormal synuclein aggregates, some of which are toxic and contribute tothe pathogenesis of the aforementioned disorders.

An abnormal ratio of monomeric to oligomeric synuclein species in plasmaexosomes of a patient is proposed to be a diagnostic hallmark of asynucleinopathy and thus, for example, of one of the aforementionedneurodegenerative disorders of the human CNS.

PD is a common neurodegenerative disorder of the human CNS, firstdescribed by James Parkinson in 1817. It has three major clinical signs:resting tremor, bradykinesia, and muscular rigidity. In addition,postural instability and various neurobehavioral disabilities may occur.In the U.S. alone it is estimated that over 1 million individuals areafflicted by this inexorably progressive disorder. Moreover, PDprevalence continues to rise along with the general aging of theAmerican population. Parkinsonian signs are now believed to largelyreflect a progressive loss of dopaminergic neurons within thenigrostriatal system. The cause of this degenerative process remainsincompletely understood, but now appears to involve the misprocessing ofalpha-synuclein into abnormal neurotoxic species.

LBD is one of the most common types of progressive dementia. The centralfeatures of LBD include progressive cognitive decline, visualhallucinations, and parkinsonian motor symptoms, such as slowness ofmovement, difficulty walking, and muscular rigidity. Some may alsosuffer from depression. The symptoms of LBD are caused by the selectiveloss of nerve cells, presumably a result of synuclein misprocessing andassociated with the build-up of Lewy bodies, spherical synucleinaccumulations inside many of the degenerating neurons. Researchers donot know why alpha-synuclein accumulates into Lewy bodies or howsynuclein species can cause the symptoms of LBD . The formation of LBDshave been considered to be a marker for PD; however, LBDs have also beenobserved in approximately 60% of both sporadic and familial cases ofAlzheimer's disease (AD) (Al-Mansoor et al.

2013). Accordingly, the aggregation of a-synuclein has been stronglyimplicated as a critical step in the development of neurodegenerativediseases (Al-Mansoor et al. 2013).

Sporadic PD or brainstem-predominant type LBD, and dementia with Lewybodies (DLB) are the two most frequent a-synucleinopathies, and areprogressive multisystem neurodegenerative disorders with widespreadoccurrence of a-synuclein deposits in the central, peripheral, andautonomic nervous system (Jellinger KA 2008a). Reportedly, there isconsiderable clinical and pathologic overlap between PD (with or withoutdementia) and DLB (or LBD), corresponding to Braak LB stages 5 and 6,both frequently associated with variable Alzheimer-type pathology(Jellinger KA 2008a). Dementia often does not correlate with progressedstages of LB pathology, but may also be related to concomitant Alzheimerlesions or mixed pathologies (Jellinger KA, 2008a).

Alzheimer disease (AD) has been reported to be featured by deposition ofβ-amyloid peptides, phosphorylated tau protein (3- and 4-repeat tau) andfrequent α-synuclein (aSyn) deposits (Jellinger KA, 2008b). Lewy bodydiseases (LBD), such as sporadic Parkinson disease (PD) and dementiawith Lewy bodies (DLB), show aSyn-positive deposits in neurons,neurites, glia, and presynaptic terminals, while frontotemporaldementias present tau-positive and tau-negative, ubiquitin- andTDP-43-positive neuronal and glial inclusions (Jellinger KA, 2008b).Molecular interactions between major proteins, which may occur withinthe same brain in various distribution patterns, cause variablephenotypes and mixed pathologies, e.g. AD with aSyn pathology in thebrainstem and amygdala, PD and DLB with AD lesions, and frontotemporaldementia with a mixture of various deposits, while others are featuredby one principal pathology without other lesions (e.g.tangle-predominant type of dementia, pure PD, brainstem-predominant LBD)(Jellinger KA, 2008b).

MSA with orthostatic hypotension is the current term for a neurologicaldisorder that was once called Shy-Drager syndrome. A progressivedisorder of the central and autonomic nervous systems, it ischaracterized by orthostatic hypotension (an excessive drop in bloodpressure when standing up), which causes dizziness and fainting.Multiple system atrophy can occur without orthostatic hypotension, butinstead have urinary tract involvement (urgency/incontinence).Neurologists classify the disorder into 3 types: the parkinsonian-typeincludes symptoms of Parkinson's disease such as slow movement, stiffmuscles, and tremor; the cerebellar-type, which causes problems withcoordination and speech; and the combined-type, which includes symptomsof both parkinsonism and cerebellar dysfunction. Problems with urinaryincontinence, constipation, and sexual impotence may happen early in thecourse of the disease. Other symptoms include generalized weakness,double vision or other vision disturbances, difficulty breathing andswallowing, sleep disturbances, and decreased sweating. Because thedisease resembles others, a correct diagnosis may take years.

Mutations in the glucocerebrosidase gene (GBA) can result in theautosomal recessive disorder Gaucher disease, Different lines ofevidence suggest that mutant GBA may be a risk factor for Parkinson'sdisease. GBA mutations are now thought to be the single largest riskfactor for development of idiopathic PD. Clinically, on imaging andpharmacologically, GBA PD is almost identical to idiopathic PD (O'Reganet al, 2017). The molecular mechanisms which lead to this increased PDrisk in GBA mutation carriers are not fully elucidated, but have beenshown to be associated with accumulation of synuclein (Soria et al,2017).

Several other disorders have also, albeit less frequently, beenconsidered synucleinopathies. These include Hallevorden-Spatz syndrome,neuronal axonal dystrophy, and some cases of traumatic brain injury. Inthe case of Hallevorden-Spatz, symptoms include parkinsonism, dystonia,dysphagia/dysarthria, rigidity or stiffness of the limbs, dementia andspasticity.

Many now believe that processes leading to synuclein oligomerization andaggregation may be central to the cellular injury and destructionoccurring in these disorders. The mechanism of alpha-synucleinaggregation in these synucleinopathies remains poorly understood.Current evidence suggests the conversion of an alpha helical structureinto a beta pleated conformation and subsequent oligomerization might bethe pathogenic antecedents to the aggregation and fibrillization ofsynuclein. These characteristics are similar to the aberrant processingof prion proteins that also can become highly neurotoxic.Phosphorylation of alpha-synuclein at the serine-129 residue has beenimplicated as a contributory factor (Chen et al 2016). According to thisauthor, a prion form of alpha-synuclein could be a causal agent,especially for multiple system atrophy (Prusiner SB et al. 2015). Prionsare small proteins that also can misfold, oligomerize, aggregate andpropagate to other cells. The result in brain is a profound andspreading neurotoxic process. Accordingly, inhibiting the initialmisfolding, oligomerization and aggregation of synuclein may bebeneficial in slowing or even arresting the progression ofsynucleinopathic disorders.

As mentioned above, alpha-synuclein readily passes into extracellularspaces and has been identified in cerebrospinal fluid, blood, urine, andsaliva (Marques and Outeiro, 2012). The mechanisms of alpha-synucleinexcretion are not fully understood, but studies have demonstrated thatat least a fraction of alpha-synuclein is excreted within exosomes, the40 nm to 100 nm vesicles of endocytic origin (reviewed in Shi et al.2014). The ratio of monomeric to oligomeric species in plasma exosomesoriginating from the CNS may correlate with disease severity (Shi et al.2014), thus suggesting that plasma exosomal alpha-synuclein and relatedspecies can help monitor disease. Similarly, exosomal alpha-synucleinlevels correlated with severity of impairment in cross-sectional samplesfrom patients with LBD (Stuendl et al. 2016).

Based on the above, drugs that normalize the ratio of monomeric tooligomeric alpha-synuclein species in plasma exosomes deriving frombrain should slow or even arrest the neurodegenerative processassociated with the synucleinopathies.

Various compositions for the treatment of PD and related disorders thattarget the synuclein aggregation pathway have been proposed. Thediscovery process primarily involves cellular and animal models ofprion- and synuclein-induced neurodegeneration (Prusiner SB 2015;Visanji NP et al. 2016). Unfortunately, none of these models has beenvalidated and all are currently regarded uncertain predictors of effectsin humans. Nevertheless, these models continue to be widely used in theabsence of better discovery techniques.

Pharmaceutical agents currently proposed for consideration include, forinstance, such small molecules as(S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine(pramipexole) and its analogues, alone or in combination with variousdrugs such as fluoxetine.

Fluoxetine,1-methylamino-3-phenyl-3-[4-(trifluoromethyl)phenoxy]propane, is aselective serotonin reuptake inhibitor (SSRI) antidepressant. It iscurrently used in the treatment of major depressive disorder,obsessive-compulsive disorder (OCD), bulimia nervosa, panic disorder,and premenstrual dysphoric disorder. When taken by mouth at recommendedmaintenance IR-doses (20 mg to 80 mg daily in 1 to 2 divided doses), orER-dose (90 mg once weekly) by patients with these disorders, fluoxetinetypically evinces a high degree of efficacy.

The mechanism by which fluoxetine benefits patients withpsycho-affective disorders is generally considered to be linked to thedrug's ability to augment CNS serotonin—mediated transmission. Inaddition, however, large fluoxetine doses in rodents have been shown toinduce a significant increase in extracellular concentrations ofnorepinephrine and dopamine after acute systemic administration(Bymaster et al. 2002).

Fluoxetine augments levels of neurotrophic factors such as glial-derivedneurotrophic factor (GDNF) and brain-derived neurotrophic factor (BDNF)and, in addition, the effects of fluoxetine in in vivo transgenic modelsof alpha-synucleinopathy have received careful investigative attention.

It has also been extensively reported to exhibit neuroprotectiveactivity in various cellular and animal models of neurodegenerativedisease (Ubhi K et al. 2012).

For example, a laboratory study examined the effect of fluoxetine in theMBP1-hα-syntg mice, a model of MSA (Shults, et al. 2005).

Fluoxetine can protect against 6-OHDA (6-hydroxydopamine) (Suzuki, etal. 2010) and MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine)(Chung, et al. 2011)-induced damage in toxin-induced models of PD.

Nevertheless, no evidence has been reported showing that fluoxetineexerts disease modifying effects in humans with a neurodegenerativedisease such as PD, or even modifies synuclein species in blood exosomalbiomarkers of synucleinopathies of this type.

As mentioned above, (S)-6-propylamino-4,5 ,6,7-tetrahydro- 1,3-benzothiazole-2 -amine (pramipexole) and its analogues, alone or incombination with various drugs have also been considered for thetreatment of PD and related disorders. Pramipexole is a syntheticaminothiazole derivative described in U.S. Pat. No. 4,886,812, thecontent of which is incorporated herein by reference. It is a dopamineagonist of the non-ergoline class (Schneider CS and Mierau J, 1987) thatis approved since the late 1990s for the treatment of the symptomatictreatment of Parkinson's disease (PD), in doses ranging from 0.375mg/day to 4.5 mg/day, given in 3 equally divided doses (Mirapex®Prescribing Information, July 2016). Pramipexole is supplied in tabletsfor immediate release containing 0.125 mg, 0.25 mg, 0.5 mg, 1 mg and 1.5mg of pramipexole dihydrochloride monohydrate; and in tablets forextended release containing 4.5 mg of pramipexole dihydrochloridemonohydrate.

Although pramipexole is widely used for the relief of parkinsoniansymptoms, its potential as a disease modifying agent has made it theobject of considerable investigative attention.

Pramipexole reportedly diminishes synuclein oligomer formation in vitro(Ono et al. 2013). Related studies suggest that pramipexole inhibits thetoxic effects of rotenone on dopaminergic neurons in a mouse PD modelwhile reducing immunoreactivity for alpha-synuclein; additionally,pramipexole decreases the in vitro oligomerization of human wild-typealpha-synuclein by H₂O₂ plus cytochrome c (Inden et al. 2009).Pramipexole has also been observed to inhibit the aggregation ofalpha-synuclein in human neuroblastoma SH5Y cells (Kakimura et al.2001). Importantly, the relative expression of α-synuclein in serumexosomes has been found to decline during pramipexole treatment ofPD-type patients, especially those manifesting acute symptomatic benefit(Luo et al. 2016); an observation of considerable interest since animalmodel studies have indicated that changes in plasma exosomal synucleinspecies correlate with changes in the CNS (Shi et al. 2014).

In addition, it began to be reported that pramipexole can exertneuroprotective effects in various in vitro cellular and in vivo animalmodels of PD. Mechanisms by which these protective effects may occurremain uncertain. Unfortunately, the protective effects of pramipexolein animal models are generally small and require higher doses thanconsidered safe and tolerable for human administration. It is thushardly surprising that pramipexole, in doses approved for the treatmentof motor symptoms of PD failed to evidence neuroprotective (i.e.,disease modifying) activity in a randomized, controlled, clinical trialinvolving 535 PD patients (Schapira et al. 2013).

(R)/(S)-mixtures, consisting of pharmaceutical compositions comprising atherapeutically effective amount of dexpramipexole or pharmaceuticallyacceptable salts and solvates thereof and a therapeutically effectiveamount of pramipexole or pharmaceutically acceptable salts and solvatesthereof, useful for the treatment of PD, are disclosed in U.S.2008/0014259, the contents of which are incorporated herein in theirentirety by reference.

According to U.S. 2008/0014259, both enantiomers are able to conferneuroprotective effects by their ability to accumulate in brain cells,the spinal cord and mitochondria where they exert a positive effect onneurological function that is independent of the dopamine agonistactivity of pramipexole. In particular, said document proposes saidcomposition as a neuroprotective agent and a therapeutically effectiveamount of from about 0.0625 mg to about 6 mg of pramipexole incombination with up to 5000 mg of dexpramipexole. However, this documentemphasizes the pramipexole adverse effects due to its dopaminergicaction and tends to privilege pramipexole low doses, as also confirmedby the same applicant in the almost concurrent WO 2008/113003, thecontents of which are incorporated herein in their entirety byreference.

According to U.S. 2013/0116292, the contents of which are incorporatedherein in their entirety by reference, dexpramipexole, orpharmaceutically acceptable salts and solvates thereof, acts by slowingthe progression of neuronal degeneration and/or by preventing neuronalcell death. However, no further mention of this possible noteworthyaction of dexpramipexole appeared in the literature.

A synthesis of dexpramipexole and of pharmaceutically acceptable saltsthereof, in particular dexpramipexole dihydrochloride monohydrate, isdescribed in U.S. 2012/0253047, the contents of which are incorporatedherein in their entirety by reference.

Unfortunately, limitations associated with the administration ofpramipexole to synucleinopathic patients limit its use at thepotentially higher neuroprotective doses predicted by many animalmodels. First, mechanisms to explain its putatively beneficial effectson synuclein-related neurotoxicity continue to elude full understanding.Second, effect sizes in animal model studies tend to be small and occuronly at relatively high drug doses. Both situations were also observedin the above mentioned report of pramipexole-induced changes in exosomalsynuclein in PD patients, which were associated with the administrationof the highest—4.5 mg/day—approved dose of pramipexole (Mirapex PackageInsert; Revised July 2016).

In the report by Luo et al. (2016), although treatment of Parkinsonpatients with pramipexole at approved therapeutic doses significantlylowered the relative expression of alpha-synuclein (compared withpre-treatment values), the magnitude of the effect was small. Higherdoses of pramipexole could have been more efficacious, but side effectssuch as vomiting and severe nausea preclude the use of higher doses. Forexample, Corrigan et al (2000) report that doses of 5 mg/day ofpramipexole, hardly higher than the maximum recommended dose of 4.5mg/day (Pramipexole FDA-approved package Insert) caused nausea in 76% ofpatients and vomiting in 39% of patients. Furthermore, 36% of patientswere not able to complete the study, presumably because of intolerableGI adverse events.

In conclusion, notwithstanding the massive existing literature, inparticular Willner et al. 1994, Corrigan et al 2000, and the disclosuresof U.S. 2008/0014259, U.S. 2011/0071135 and US 2014/0024644, nobodysucceeded in safely increasing pramipexole efficacy, and pramipexolecurrently provides only marginal activity in the treatment ofParkinson's disease. There is no clinical demonstration of aneuroprotective effect of pramipexole, or of any disease modifyingaction by pramipexole, in patients suffering from a synucleinopathicdisease such as PD.

Practical limitations associated with the safety and tolerability ofadministering pramipexole to synucleinopathic patients at the high,neuroprotective doses generally predicted by animal models pose asignificant challenge. The effects of pramipexole in animal modelstudies tend to be small and occur only at relatively high doses. Aswith most pharmaceuticals, higher doses of pramipexole generally producemore frequent and severe adverse effects along with improved therapeuticefficacy. Side effects of the approved doses, often dose-limiting,include somnolence, confusion, postural hypotension, and hallucinations(Mirapex Package Insert, Revised July 2016).

The document U.S. Pat. No. 6,667,329 (see also WO00/06162), the contentsof which are incorporated herewith in their entirety by reference,discloses a combination of pramipexole with another antidepressant forthe treatment of depression. Said other antidepressant may bealprazolam, fluoxetine, opipramol, amitriptyline, fluvoxamine,paroxetine, amitriptyline oxide, imipramine, sertraline,chlordiazepoxide, lofepramine, sulpiride, citalopram, maprotiline,tranylcypromine, clomipramine, mianserin, trazodone, quinpirole,mirtazapine, trimipramine, dibenzepin, moclobemide, tryptophan, doxepin,nefazodone, venlafaxine, nortriptyline or viloxazine. According to U.S.Pat, No. 6,667,329, pramipexole combined with another antidepressant hasa significantly greater antidepressant activity than either of the twoindividual components taken alone, the improvement in the effect ofpramipexole by the simultaneous administration of another antidepressanthaving been discovered in tests on rats using the forced swimming test.Said combination may be a fixed-dose combination. Notwithstanding theknowledge of extensive studies of the effects of fluoxetine andpramipexole, separately, on alpha-synuclein processing over the past tenyears, and notwithstanding that the disclosure of thefluoxetine-pramipexole combination in the treatment of the depressionwas known for about seventeen years, no one has disclosed or suggested acombination of fluoxetine-pramipexole which could be used for treatingsynucleinopathies, for example PD, or that, at safe and tolerable doses,fluoxetine and pramipexole combined would be found to modify synucleinspecies in blood exosomes in ways and to degrees indicative ofsignificant disease modifying efficacy.

SUMMARY OF THE INVENTION

The present invention increases the therapeutic window for pramipexole,to safely enable its full neuroprotective efficacy to a degree thatdelays onset and/or slows symptom progression to a clinicallysignificant extent in those suffering from a synucleinopathy, such asthose with PD-like disorders.

One approach to this end is to administer a drug that actssynergistically with pramipexole, to for instance, reduce the minimumeffective dose for pramipexole and/or increases pramipexole's efficacywithout diminishing its minimum toxic dose. The antidepressantfluoxetine exhibits these properties when combined with pramipexole.

It has now been found that an antidepressant such as fluoxetine acts byaugmenting the synucleinopathy-modifying potential of pramipexole inhumans, thus allowing at least a slowing of the disease progression atdoses that are both safe and tolerable. In addition, it has been foundthat an antidepressant such as fluxetine allows for the safeadministration of6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine at a dailydose comprising a (S)-enantiomer dose that may be higher, and even muchhigher, than the pramipexole maximum daily dose recommended for therelief of the symptomatic treatment of Parkinson's disease.Consequently, an improvement of the conditions of a patient sufferingfrom a synucleinopathy, in particular PD, Lewy body disease,parkinsonian disorders associated with glucocerebrosidase (GBA)mutations, and MSA is attained.

The combination of an antidepressant such as fluoxetine or of apharmaceutically acceptable salt or solvate thereof with a6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine or apharmaceutically acceptable salt or solvate thereof, acts to normalizelevels of synuclein species in the plasma of patients suffering from asynucleinopathy, in particular by diminishing the concentration ofabnormal synuclein species (congeners) in the patient's plasma and inthe exosomal vesicles found therein, to a significant degree at dosesthat are safe and tolerable thus evidencing that said patients willenjoy neuroprotective benefit.

This observation is unexpected since neither drug has been foundclinically to possess any disease modifying ability in patients with asynuclein related disorder. Moreover, nowhere has it even been suggestedthat the combination of these drugs might confer such significantbenefit to such individuals since the antiparkinson drug and theantidepressant drug primarily act by very different mechanisms.

The present invention is based on the discovery that

-   an antidepressant such as fluoxetine potentiates (augments) the    ability of pramipexole to alter blood exosomal synuclein species in    ways indicating the activation of a central neuroprotective    mechanism, i.e. reducing oligomerization of synuclein:-   these changes occur at safe and tolerable doses of both drugs; and-   these changes are indicative of CNS changes that will confer disease    clinical improvement in a way and to a degree that will provide    practical and significant disease modifying benefit to sufferers.

The findings are unexpected since, in spite of numerous publications onpramipexole and on fluoxetine and their combination, no observations onthis possibility were reported, mentioned or suggested, and nospeculation on its consequences were found. Moreover, it is unexpectedsince the two drugs act on different targets, by different mechanisms,to produce different clinical effects, and thus would hardly be expectedto have synergistic effects in the manner disclosed herein.

In addition, it has also surprisingly been found that an antidepressantsuch as fluoxetine attenuates the GI adverse effects of pramipexole,thus allowing the safe administration of pramipexole within the wholepramipexole recommended daily dose range (0.375 mg-4.5 mg) and also atdoses higher than the maximum recommended daily dose, for example from4.5 mg to 6 mg, from more than 6 mg to 10 mg, from 6.5 mg to 10 mg andeven from 6.5 mg to 15 mg or from 6.5 mg to 20 mg.

These findings thus allow the treatment of disabling synucleinopathiessuch as PD, LBD, mutations in the glucocerebrosidase (GBA) gene,Alzheimer's disease, the Lewy body variant of AD, neurodegeneration withbrain iron accumulation, and MSA.

Thus, the present invention provides a method for treating a patientsuffering from a synucleinopathy, which comprises administering to saidpatient in need of said treatment an antidepressant such as fluoxetineor a pharmaceutically acceptable salt or solvate thereof in combinationwith a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or ofa pharmaceutically acceptable salt or solvate thereof.

Pharmaceutically acceptable salts of6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine are alsoincluded in the present invention.

The invention also provides a combination of an antidrepressant such asfluoxetine or of a pharmaceutically acceptable salt or solvate thereof,normally at a daily dose that is at least as high as the dose approvedfor the prevention or treatment of depression, and an effective dailydose of a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine ora pharmaceutically acceptable salt or solvate thereof, for use for thetreatment of synucleinopathies.

Preferably, the method for treating a patient suffering from asynucleinopathy according to the present invention comprisesadministering to said patient in need of said treatment, an effectivedaily dose of fluoxetine hydrochloride that is at least as high as thedose approved for the treatment of depression, and an effective dailydose of pramipexole dihydrochloride monohydrate.

According to an embodiment, fluoxetine or a pharmaceutically acceptablesalt or solvate thereof and the6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or apharmaceutically acceptable salt or solvate thereof are each formulatedin a pharmaceutical composition in admixture with a pharmaceuticalcarrier and concurrently or sequentially administered to a patient inneed of said treatment.

According to another embodiment, fluoxetine or a pharmaceuticallyacceptable salt or solvate thereof and the6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or apharmaceutically acceptable salt or solvate thereof are mixed togetherand formulated in a pharmaceutical composition (fixed-dose combination)in admixture with a pharmaceutical carrier, to be administered to thepatient in need of said treatment.

According to an advantageous embodiment, in the method (or use) for thetreatment of a synucleinopathy, fluoxetine or a pharmaceuticallyacceptable salt or solvate thereof is formulated in a pharmaceuticalcomposition in admixture with a pharmaceutical carrier or vehicle. Thiscomposition is administered to a patient in need of said treatment at adaily dose that is equivalent to from 5 mg to 90 mg of fluoxetine base,in combination with a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine orpharmaceutically acceptable salt or solvate thereof. Said6-propylamino-4,5 ,6,7 -tetrahydro- 1,3 -benzothiazole-2-amine is alsoformulated in a pharmaceutical composition in admixture with apharmaceutical carrier or vehicle and is administered to said patient inneed of said treatment at a daily dose that is equivalent to from 1.5 mgto 3000 mg of pramipexole dihydrochloride monohydrate, said daily doseincluding an (S)-enantiomer daily dose equivalent to from 1.5 to 20 mg,from 1.5 mg to 15 mg, froml.5 mg to 10 mg, from 1.5 mg to 7.5 mg, orfrom 1.5 mg to 6 mg of pramipexole dihydrochloride monohydrate.

In said method (or use), said fluoxetine and said 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine combination is administered tosaid patient in a fixed-dose combination wherein said fluoxetine andsaid 6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine aremixed together, and with a pharmaceutical carrier or vehicle.

Preferably, fluoxetine is used as fluoxetine hydrochloride and the 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine is used aspramipexole dihydrochloride monohydrate.

DETAILED DESCRIPTION

The present invention is based on the discovery that the anantidepressant agent such as fluoxetine will synergistically andsubstantially improve the ability of safe and tolerable doses of6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine to reducetoxic synuclein oligomers in plasma exosomes of patients with PD andrelated synucleinopathic disorders, and thus benefit patients with suchfatal disorders to a previously unrealized degree.

As set forth above, these results are totally unexpected since

-   the ability of fluoxetine to augment the biomarker response to    pramipexole to a degree that confers clinical patient benefit has    never before been described, suggested or even anticipated in view    of the lack of a rational basis and differences in the drugs'    pharmacologic properties including their mechanisms of action; and-   no drug or drug combination, let alone this particular combination,    has ever been found to have convincing neuroprotective efficacy    potential in humans with synucleinopathies.

Specific Aspects Of The Invention

Thus, according to a first aspect, the present invention provides amethod for treating a patient suffering from a synucleinopathy, whichcomprises administering to a patient in need of said treatment aneffective yet tolerable daily dose of fluoxetine or a pharmaceuticallyacceptable salt or solvate thereof in combination with an effectivedaily dose of a6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or apharmaceutically acceptable salt thereof.

Herein below, the expressions “salts or solvates thereof” and “salts andsolvates thereof”, in reference to fluoxetine or a6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine, indicatethat the salt of said fluoxetine or said 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine may be solvated with a solvent,normally water.

Herein, “fluoxetine” stands for 1-methylamino-3-phenyl-3 -[4-(trifluoromethyl)phenoxy]propane as the free base or a salt or solvatethereof. Fluoxetine may be used as free base or as its hydrochloridesalt.

The 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine isselected from the group consisting of

-   (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (as    the racemate) and pharmaceutically acceptable salts and solvates    thereof;-   (S)-propylamino-4,5 ,6,7-tetrahydro- 1,3 -benzothiazole-2-amine    (INN: pramipexole) and pharmaceutically acceptable salts thereof, in    particular its dihydrochloride monohydrate (USAN: pramipexole    hydrochloride); and-   a (R)/(S)-mixture consisting of a pharmaceutical composition    comprising an effective amount of dexpramipexole and an effective    amount of pramipexole, said pramipexole being referred to as    “(S)-enantiomer” in said (R)/(S)-mixtures.

The neuroprotective activity of (R)-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or pharmaceutically acceptable salts and solvatesthereof, that is not dopaminergic, is disclosed in U.S. 2013/0116292,the contents of which are incorporated herein in their entirety byreference. According to this document, said (R)-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or pharmaceutically acceptablesalts and solvates thereof acts by slowing the progression of neuronaldegeneration and/or by preventing neuronal cell death.

(R)/(S)-mixtures, consisting of pharmaceutical compositions comprising atherapeutically effective amount of (R)-propylamino-4,5 ,6,7-tetrahydro-1,3 -benzothiazole-2 -amine or pharmaceutically acceptable salts andsolvates thereof and a therapeutically effective amount of(S)-propylamino-4,5 ,6,7-tetrahydro-1,3 -benzothiazole-2-amine aredisclosed in the aforementioned U.S. 2008/0014259, the contents of whichare incorporated herein in their entirety by reference.

The term “effective daily dose of fluoxetine”, as used herein, refers toa daily dose of fluoxetine hydrochloride equivalent to a fluoxetine basedose that is at least as high as an approved daily dose for thetreatment of depression.

As set forth in the definitions, “fluoxetine” generally stands for theactive principle per se, independently of the salt or solvate of saidactive principle, and “6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine” generallystands for the active principle per se, independently of the stericconfiguration and of the salt or solvate of said active principle.

In particular,

-   the term “fluoxetine” includes the free base and pharmaceutically    acceptable salts and solvates thereof, their doses per unit form or    their daily doses being expressed as equivalents of fluoxetine    base.; and-   the term    “6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine” refers    to 6 -propylamino-4,5 ,6,7 -tetrahydro-1,3 -benzothiazole-2-amine    and pharmaceutically acceptable salts and solvates thereof, their    doses per unit form or their daily doses being expressed as    equivalents of pramipexole dihydrochloride monohydrate.

Pharmaceutically acceptable salts or solvates of fluoxetine and of 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine are alsoincluded in the present invention. Illustrative examples of these saltsinclude acid addition salts with mineral acids such as hydrochloricacid, hydrobromic acid, hydriodic acid, sulfuric acid, nitric acid,phosphoric acid and the like or with organic acids such as formic acid,acetic acid, propionic acid, oxalic acid, malonic acid, succinic acid,fumaric acid, maleic acid, lactic acid, malic acid, tartaric acid,citric acid, carbonic acid, methanesulfonic acid, ethanesulfonic acid,aspartic acid, glutamic acid and the like. The solvation agent isgenerally water.

In the method (or use) for the treatment of a synucleinopathy such asPD, LBD, AD, mutations in the glucocerebrosidase gene, and MSA,fluoxetine or a pharmaceutically acceptable salt or solvate thereof isformulated in a pharmaceutical composition in admixture with apharmaceutical carrier or vehicle. This composition is administered to apatient in need of said treatment at a daily dose that is equivalent tofrom 5 mg to 90 mg of fluoxetine base, in combination with a6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine orpharmaceutically acceptable salt or solvate thereof. Said6-propylamino-4,5,6,7 -tetrahydro-1,3-benzothiazole-2-amine is alsoformulated in a pharmaceutical composition in admixture with apharmaceutical carrier or vehicle and is administered to said patient inneed of said treatment at a daily dose that is equivalent to from 1.5 mgto 3000 mg of pramipexole dihydrochloride monohydrate, said daily doseincluding an (S)-enantiomer daily dose equivalent to from 1.5 to 20 mg,from 1.5 mg to 15 mg, from1.5 mg to 10 mg, from 1.5 mg to 7.5 mg, orfrom 1.5 mg to 6 mg of pramipexole dihydrochloride monohydrate.

In said pharmaceutical composition, the6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine orpharmaceutically acceptable salt or solvate thereof is selected from thegroup consisting of

-   (S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or a    pharmaceutically acceptable salts and solvates thereof, in an amount    per unit form equivalent to from 0.125 mg to 20 mg of pramipexole    dihydrochloride monohydrate;-   (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    (the racemate) and pharmaceutically acceptable salts and solvates    thereof, in an amount per unit form equivalent to from 0.25 mg to 40    mg of pramipexole dihydrochloride monohydrate; and-   a (R)/(S)-mixture. comprising    6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, in an    amount per unit form equivalent to from 50 mg to 3000 mg of    pramipexole dihydrochloride monohydrate, said amount per unit form    including a (S)-enantiomer amount equivalent to from 0.125 mg to 20    mg of pramipexole dihydrochloride monohydrate and    (R)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, in    an amount equivalent to from 50 mg to 3000 mg (minus from 0.125 mg    to 20 mg) of pramipexole dihydrochloride monohydrate. Normally, in    the pharmaceutical composition to be administered in combination    with the above illustrated fluoxetine pharmaceutical composition,    the 6-propylamino-4,5,6,7 -tetrahydro-1,3-benzothiazole-2-amine is    preferably selected from the group consisting of-   (S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (INN:    pramipexole) and pharmaceutically acceptable salts and solvates    thereof, in particular its dihydrochloride monohydrate (USAN:    pramipexole hydrochloride), in a dose per unit form equivalent to    from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg to 10    mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to 6 mg of pramipexole    dihydrochloride monohydrate;-   (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    (the racemate) and pharmaceutically acceptable salts an solvates    thereof, in a dose per unit form equivalent to from 0.25 mg to 40    mg, from 0.25 mg to 30 mg, from 0.25 mg to 20 mg, from 0.25 mg to 15    mg, or from 0.25 mg to 12 mg of pramipexole dihydrochloride    monohydrate (thus, obviously, including a dose per unit form of    (S)-enantiomer equivalent to from 0.125 mg to 20 mg, from 0.125 mg    to 15 mg, from 0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from    0.125 mg to 6 mg of pramipexole dihydrochloride monohydrate, and a    dose per unit form of    (R)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    equivalent to from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from    0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to 6 mg    of pramipexole dihydrochloride monohydrate); and-   (R)/(S)-mixture. i.e. a pharmaceutical composition in dosage unit    form comprising 6    -propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, at a dose    per unit form equivalent to from 50 mg to 3000 mg, preferably to    from 150 mg to 3000 mg, of pramipexole dihydrochloride monohydrate,    said amount per unit form including a (S)-enantiomer amount    equivalent to from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from    0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to 6 mg    of pramipexole dihydrate monohydrate, thus, obviously, said amount    per unit form being constituted by an amount of (S)-enantiomer    equivalent to from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from    0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to 6 mg    of pramipexole dihydrochloride monohydrate and by a    (R)-6-propylamino-4,5,6,7 -tetrahydro-1,3-benzothiazole-2-amine    amount per unit form equivalent to from 50 mg (or 150 mg) to 3000 mg    (minus from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg    to 10 mg, from 0.125 mg to 7.5 mg, or from 0.125 to 6 mg) of    pramipexole dihydrochloride monohydrate).

The dose of the6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, per IR-unitform, will range from 0.125 mg to 1500 mg, said dose including a(S)-isomer amount per IR-form equivalent to from 0.125 mg to 10 mg, from0.125 mg to 7.5 mg, from 0.125 mg to 5 mg, from 0.125 mg to 3.75 mg, orfrom 0.125 to 3 mg of pramipexole dihydrochloride monohydrate, dependingon safety and tolerability (in combination with fluoxetine, in the abovedose/unit form). The dose of the6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, per

ER-unit form, will range from 0.375 mg to 3000 mg, said dose including a(S)-isomer amount per ER-form equivalent to from 0.375 mg to 20 mg, from0.375 mg to 15 mg, from 0.375 mg to 10 mg, from 0.375 mg to 7.5 mg, orfrom 0.375 to 6 mg of pramipexole dihydrochloride monohydrate, dependingon safety and tolerability (in combination with fluoxetine, in the abovedose/unit form).

The dose of pramipexole or pharmaceutically acceptable salt thereof, perIR-unit form, will be equivalent to from 0.125 mg to 10 mg, from 0.125mg to 7.5 mg, from 0.125 mg to 5 mg, from 0.125 mg to 3.75 mg, or from0.125 mg to 3 mg of pramipexole dihydrochloride monohydrate, dependingon safety and tolerability (in combination with fluoxetine, in the abovedose/unit form).

The dose of pramipexole or pharmaceutically acceptable salt thereof, perER-unit form, will be equivalent to from 0.375 mg to 20 mg, from 0.375mg to 15 mg, from 0.375 mg to10 mg, from 0.375 mg to 7.5 mg, or from0.375 mg to 6 mg of pramipexole dihydrochloride monohydrate, dependingon safety and tolerability (in combination with fluoxetine, in the abovedose/unit form).

According to a second aspect, the invention provides a pharmaceuticalcombination comprising

-   (a) fluoxetine, at a dose that is at least as high as a dose    approved for the treatment of depression, and-   (b) a 6-propylamino-4,5 ,6,7 -tetrahydro-1,3 -benzothiazole-2-amine    or a pharmaceutically acceptable salt or solvate thereof, for use    for the treatment of a synucleinopathy. According to an embodiment    of this second aspect, the invention provides fluoxetine, in a    pharmaceutical composition comprising, as an active ingredient,    fluoxetine or a pharmaceutically acceptable salt or solvate thereof,    in admixture with a pharmaceutical carrier or vehicle, for use for    the treatment of a synucleinopathy in combination with    6-propylamino-4,5 ,6,7-tetrahydro- 1,3 -benzothiazole-2-amine, also    in a pharmaceutical composition in admixture with a pharmaceutical    carrier or vehicle.

According to this embodiment, said fluoxetine, or a pharmaceuticallyacceptable salt or solvate thereof, is present in said composition in anamount/unit form, in fluoxetine, at least as high as a dose/unit formapproved for the treatment of depression, in admixture with apharmaceutical carrier, for use for the treatment of a synucleinopathy,in combination with pramipexole or a pharmaceutically acceptable salt orsolvate thereof in doses, in pramipexole dihydrochloride monohydrate,approved for the relief of the symptoms of PD. According to a thirdaspect, the invention provides the use of fluoxetine for the preparationof a medicament consisting of a pharmaceutical composition comprising,as an active ingredient, said fluoxetine, or a pharmaceuticallyacceptable salt or solvate thereof, in admixture with a pharmaceuticalcarrier or vehicle, for the treatment of a synucleinopathy incombination with a6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or of apharmaceutically acceptable salt and/or solvate thereof, preferably withpramipexole or a pharmaceutically acceptable salt thereof.

Said use and said treatment of synucleinopathies according to the abovesecond aspect and third aspect of the invention are described in theabove disclosure of the first aspect of the invention. According to afourth aspect, the invention provides the use of fluoxetine for thepreparation of a medicament for the treatment of a synucleinopathy in apatient in need of said treatment, said medicament consisting of apharmaceutical composition in dosage unit form comprising, as an activeingredient said fluoxetine and, as a second active ingredient,6-propylamino-4,5 ,6,7-tetrahydro- 1,3 -benzothiazole-2-amine, inadmixture with a pharmaceutical carrier or vehicle,.

In particular, the invention provides a pharmaceutical fixed-dosecombination consisting of a pharmaceutical composition in dosage unitform comprising fluoxetine or a pharmaceutically acceptable salt orsolvate thereof, as Component (a) and a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or apharmaceutically acceptable salt or solvate thereof, preferably withpramipexole or a pharmaceutically acceptable salt thereof, as

Component (b), in admixture with a pharmaceutical carrier or vehicle

According to an embodiment of this fourth aspect, the invention providesa fixed-dose combination consisting of a pharmaceutical compositioncomprising

-   (a) fluoxetine hydrochloride, in an amount/unit form (in fluoxetine    base) at least at least as high as the amount/unit form, in    fluoxetine base, approved for the treatment of depression; and-   (b) pramipexole dihydrochloride monohydrate, in an amount/unit form    at least at least as high as an amount/unit form approved for the    treatment of Parkinson's disease, in admixture with a pharmaceutical    carrier or vehicle, for use for the treatment of synucleinopathies.

Moreover, according to an embodiment of this fourth aspect, theinvention provides the use of

-   (a) fluoxetine hydrochloride, in an amount/unit form (in fluoxetine    base) at least at least as high as the amount/unit form, in    fluoxetine base, approved for the treatment of depression; and-   (b) pramipexole dihydrochloride monohydrate, in an amount/unit form    at least at least as high as an amount/unit form approved for the    treatment of Parkinson's disease,    for the preparation of a medicament consisting of a pharmaceutical    composition comprising said fluoxetine and said pramipexole    dihydrochloride monohydrate, in admixture with a pharmaceutical    carrier or vehicle, for the treatment of synucleinopathies.

In the above compositions according to this fourth aspect, fluoxetine ora pharmaceutically acceptable salt thereof Component (a) is present inan amount equivalent to from 2 mg to 90 mg of fluoxetine hydrochlorideand said 6-propylamino-4,5,6,7 -tetrahydro-1,3-benzothiazole-2-amine ora pharmaceutically acceptable salt and/or solvate thereof is present inan amount equivalent to of from 0.125 mg to 3000 mg of pramipexoledihydrochloride monohydrate, said amount including an S-enantiomeramount equivalent to from 0.125 mg to 20 mg of pramipexoledihydrochloride monohydrate. Preferably, in the above compositions, said6-propylamino-4,5 ,6,7-tetrahydro-1,3 -benzothiazole-2-amine ispramipexole or a pharmaceutically acceptable salt thereof, in an amountequivalent to from 0.125 mg to 20 mg of pramipexole dihydrochloridemonohydrate.

The dose of fluoxetine, or of a pharmaceutically acceptable salt orsolvate thereof, per IR-unit form, will be in an amount that isequivalent to from 2 mg to 40 mg or from 5 mg to 40 mg of fluoxetinebase, depending on safety and tolerability (in combination with6-propylamino-4,5 ,6,7-tetrahydro- 1,3 -benzothiazole-2-amine).Preferably, said fluoxetine pharmaceutically acceptable salt isfluoxetine hydrochloride in the above IR-dose/unit form.

The dose/unit form of fluoxetine, or of a pharmaceutically acceptablesalt or solvate thereof, in an ER-formulation, including slow-releasecompositions and transdermal therapeutic systems such as transdermalpatches, will be in an amount (in fluoxetine) of from 20 mg to 90 mg,depending on safety and tolerability (in combination with a 6-propylamino-4,5 ,6,7-tetrahydro- 1,3 -benzothiazole-2-amine).

In particular, according to an embodiment of this fourth aspect, theinvention, provides a fixed-dose combination consisting of apharmaceutical composition which comprises

-   (a) fluoxetine, in an amount per unit form of from 2 mg to 90 mg;    and-   (b) a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    selected from the group consisting of    -   (S)-6-propylamino-4,5 ,6,7-tetrahydro-1,3 -benzothiazole-2-amine        or a pharmaceutically acceptable salts and solvates thereof, in        an amount per unit form equivalent to from 0.125 mg to 20 mg of        pramipexole dihydrochloride monohydrate;    -   (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine        (the racemate) and pharmaceutically acceptable salts an solvates        thereof, in an amount per unit form equivalent to from 0.25 mg        to 40 mg of pramipexole dihydrochloride monohydrate; and    -   a (R)/(S)-mixture comprising        6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2 -amine, in        an amount per unit form equivalent to from 50 mg to 3000 mg,        said amount per unit form including a (S)-enantiomer amount        equivalent to from 0.125 mg to 20 mgof pramipexole        dihydrochloride monohydrate and (R)-6-propylamino-4,5,6,7        -tetrahydro-1,3-benzothiazole-2-amine, in an amount equivalent        to from 50 mg to 3000 mg (minus from 0.125 mg to 20 mg) of        pramipexole dihydrochloride monohydrate; in admixture with a        pharmaceutical carrier or vehicle.

In the pharmaceutical composition to be administered in combination withthe above illustrated fluoxetine pharmaceutical composition, for examplein the fixed-dose combination according this fourth aspect of theinvention, the 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine is preferably selected from the group consistingof

-   (S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (INN:    pramipexole) and pharmaceutically acceptable salts and solvates    thereof, in particular its dihydrochloride monohydrate (USAN:    pramipexole hydrochloride), in a dose per unit form equivalent to    from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg to 10    mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to 6 mg of pramipexole    dihydrochloride monohydrate;-   (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    (the racemate) and pharmaceutically acceptable salts an solvates    thereof, in a dose per unit form equivalent to from 0.25 mg to 40    mg, from 0.25 mg to 30 mg, from 0.25 mg to 20 mg, from 0.25 mg to 15    mg, or from 0.25 mg to 12 mg of pramipexole dihydrochloride    monohydrate (thus, obviously, including a dose per unit form of    (S)-enantiomer equivalent to from 0.125 mg to 20 mg, from 0.125 mg    to 15 mg, from 0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from    0.125 mg to 6 mg of pramipexole dihydrochloride monohydrate, and a    dose per unit form of    (R)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine    equivalent to from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from    0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to 6 mg    of pramipexole dihydrochloride monohydrate); and-   (R)/(S)-mixture comprising    6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, at a    dose per unit form equivalent to from 50 mg to 3000 mg, preferably    to from 150 mg to 3000 mg, of pramipexole dihydrochloride    monohydrate, said amount per unit form including a (S)-enantiomer    amount equivalent to from 0.125 mg to 20 mg, from 0.125 mg to 15 mg,    from 0.125 mg to 10 mg, from 0.125 mg to 7.5 mg, or from 0.125 mg to    6 mg of pramipexole dihydrochloride monohydrate, thus, obviously,    said amount per unit form being constituted by an amount of    (S)-enantiomer equivalent to from 0.125 mg to 20 mg of pramipexole    dihydrochloride monohydrate and by a (R)-6-propylamino-4,5,6,7    -tetrahydro-1,3-benzothiazole-2-amine amount per unit form    equivalent to from 50 mg (or 150 mg) to 3000 mg (minus from 0.125 mg    to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg to 10 mg, from 0.125    mg to 7.5 mg, or from 0.125 to 6 mg) of pramipexole dihydrochloride    monohydrate.

The dose of the6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, per IR-unitform, will range from 0.125 mg to 1500 mg, said dose including a(S)-isomer amount per IR-form equivalent to from 0.125 mg to 10 mg, from0.125 mg to 7.5 mg, from 0.125 mg to 5 mg, from 0.125 mg to 3.75 mg, orfrom 0.125 to 3 mg of pramipexole dihydrochloride monohydrate, dependingon safety and tolerability (in combination with fluoxetine, in the abovedose/unit form).

The dose of pramipexole or pharmaceutically acceptable salt thereof, perIR-unit form, will be equivalent to from 0.125 mg to 10 mg, from 0.125mg to 7.5 mg, from 0.125 mg to 5 mg, from 0.125 mg to 3.75 mg, or from0.125 mg to 3 mg of pramipexole dihydrochloride monohydrate, dependingon safety and tolerability (in combination with fluoxetine, in the abovedose/unit form).

If said 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine orpharmaceutically acceptable salt of solvate thereof is pramipexoledihydrochloride monohydrate, the dose-range is from 0.125 mg to 10 mg,from 0.125 mg to 7.5 mg, from 0.125 mg to 5 mg, from 0.125 mg to 3.75mg, or from 0.125 mg to 3 mg per IR-unit form, depending on safety andtolerability (in combination with fluoxetine, at the above dose/unitform).

The dose/unit form of6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine in an ERformulation, including slow-release compositions and transdermaltherapeutic systems such as transdermal patches, will range from 1.5 mgto 3000 mg, said dose/unit form including a (S)-isomer amount perER-form equivalent to from 1.5 mg to 20 mg, from 1.5 mg to 15 mg, from1.5 mg to 10 mg, from 1.5 mg to 7.5 mg, or from 1.5 to 6 mg ofpramipexole dihydrochloride monohydrate, depending on the tolerabilityin combination with fluoxetine, at the above dose/unit form.

The dose of pramipexole or pharmaceutically acceptable salt thereof, perER-unit form, will be equivalent to from 1.5 mg to 20 mg, from 1.5 mg to15 mg, from 1.5 mg to 10 mg, from 1.5 mg to 7.5 mg, or from 1.5 mg to 6mg of pramipexole dihydrochloride monohydrate, depending on safety andtolerability (in combination with fluoxetine, in the above dose/unitform).

Normally, if said6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine ispramipexole dihydrochloride monohydrate or pramipexole base, thedose-range/unit form (in pramipexole dihydrochloride monohydrate), willbe from 1.5 mg to 20 mg, from 1.5 mg to 15 mg, from 1.5 mg to 10 mg,from 1.5 mg to 7.5 mg or from 1.5 mg to 6 mg per ER-unit form.

For the use of the combination of the present invention in the treatmentof synucleinopathies,

-   fluoxetine or a pharmaceutically acceptable salt thereof is    administered, preferably as fluoxetine hydrochloride, at a daily    dose (in fluoxetine base) of from 4 mg to 40 mg in a IR-or ER-form    or at a weekly dose of 90 mg, in an ER-form; and-   the 6-propylamino-4,5 ,6,7-tetrahydro-1,3 -benzothiazole-2-amine or    pharmaceutically acceptable salt thereof is administered at a daily    dose equivalent to from 1.5 mg to 3000 mg of pramipexole    dihydrochloride monohydrate in IR- or ER-form, said daily dose    including a (S)-isomer amount per IR- or ER-form equivalent to from    1.5 mg to 20 mg, from 1.5 mg to 15 mg, from 1.5 mg to 10 mg, from    1.5 mg to 7.5 mg, or from 1.5 to 6 mg of pramipexole dihydrochloride    monohydrate.

If, in said combination, said6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2 -amine ispramipexole or a pharmaceutically acceptable salt thereof, it isadministered at a daily dose that is equivalent to from 1.5 mg to 20 mg,from 1.5 mg to 15 mg, from 1.5 mg to 10 mg, from 1.5 mg to 7.5 mg, orfrom 1.5 mg to 6 mg of pramipexole dihydrochloride monohydrate,preferably as pramipexole dihydrochloride monohydrate at a daily dose offrom 1.5 mg to 20 mg, from 1.5 mg to 15 mg, from 1.5 mg to 10 mg, from1.5 mg to 7.5 mg, or from 1.5 mg to 6 mg. As described above, for theintended use, the combination of the invention comprises

-   (a) fluoxetine or a pharmaceutically acceptable salt or solvate    thereof; and-   (b) a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or    a pharmaceutically acceptable salt or solvate thereof, each in a    pharmaceutical composition in admixture with a pharmaceutical    carrier or vehicle; or-   (a/b) fluoxetine or a pharmaceutically acceptable salt or solvate    thereof; and a 6-propylamino-4,5 ,6,7-tetrahydro- 1,3    -benzothiazole-2-amine or a pharmaceutically acceptable salt or    solvate thereof, mixed together in a pharmaceutical composition in    dosage unit form, in admixture with a pharmaceutical carrier or    vehicle, as a fixed dose combination.

In the pharmaceutical compositions of the present invention for oral,subcutaneous, intravenous, transdermal or topical administration, theactive ingredients are preferably administered in the form of dosageunits, in admixture with the classic pharmaceutical carriers orvehicles.

The dosage, i.e. the amount of active ingredient in a single dose to beadministered to a patient suffering from a synucleinopathy patient, canvary widely depending on the age, weight, and the health condition ofthe patient, as also illustrated herein above. This dosage includes theadministration of a dose per unit form of from 2 mg to 40 mg offluoxetine, and from 0.125 mg to 1500 mg of6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, according tothe age of the patient, from one to three times a day by intravenous,subcutaneous, oral, or transcutaneous administration, according to thestrength of the doses of the each of the active ingredients.

If fluoxetine is as hydrochloride, said dosage is from 2 mg to 90 mg (influoxetine base).

If 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine ispramipexole or a pharmaceutically acceptable salt thereof, said dosageis equivalent to from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from0.125 mg to 10 mg, from 0.125 mg to 7.5 mg or from 0.125 mg to 6 mg ofpramipexole dihydrochloride monohydrate.

If 6-propylamino-4,5 ,6 ,7-tetrahydro- 1,3 -benzothiazole-2-amine ispramipexole dihydrochloride monohydrate, said dosage ranges from 0.125mg to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg to 10 mg, from 0.125mg to 7.5 mg or from 0.125 mg to 6 mg.

Thus, according to a preferred embodiment the present invention providesa fixed-dose combination consisting of a pharmaceutical compositioncomprising

-   (a) fluoxetine or a pharmaceutically acceptable salt thereof, in an    amount per unit form equivalent to from 2 mg to 90 mg of fluoxetine    base; and-   (b) pramipexole or a pharmaceutically acceptable salt thereof, in an    amount per unit form equivalent to a range selected from the group    consisting of from 0.125 mg to 20 mg, from 0.125 mg to 15 mg, from    0.125 mg to 10 mg, from 0.125 mg to 7.5 mg or from 0.125 mg to 6 mg    of pramipexole dihydrochloride monohydrate, in admixture with a    pharmaceutical carrier or vehicle.

The pharmaceutical compositions of the present invention are formulatedwith the classic excipients suitable for different ways ofadministration. Particularly advantageous are the formulations in theform of tablets, multi-score tablets, coated tables, orallydisintegrating tablets, extended release tablets, hard or soft capsules,extended-release capsules, patches for transdermal administration,liquid oral solutions, syrups or suspensions in a predetermined unitform, and vials for the intravenous or subcutaneous administration.

Thus, for example, a pharmaceutical composition according to the presentinvention to be chronically administered in combination with6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine, preferablypramipexole dihydrochloride monohydrate, in an amount/unit dose of from0.125 mg to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg to 10 mg, from0.125 mg to 7.5 mg or from 0.125 mg to 6 mg to be administered at adaily dose of from 1.5 mg to 20 mg, from 1.5 mg to 15 mg, from 1.5 mg to10 mg, from 1.5 mg to 7.5 mg, or from 1.5 mg to 6 mg, comprisesfluoxetine hydrochloride, in an amount/unit dose (in fluoxetine) of from2 mg to 90 mg to be administered at a daily dose of from 4 mg to 40 mgin IR or ER-form or at a weekly dose of 90 mg, in ER-form only.

The pharmaceutical compositions may be formulated in oral forms such astablets or gelatin capsules, wherein fluoxetine or a pharmaceuticallyacceptable salt or solvate thereof; or the6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, preferablypramipexole or a pharmaceutically acceptable salt or solvate thereof; orboth the active ingredients, are in admixture with a carrier or vehicle.Said carrier or vehicle may include a diluent, such as cellulose,dextrose, lactose, mannitol, sorbitol or sucrose; a lubricant, such as,acid, calcium or magnesium stearate, polyethylene glycol, silica, ortalc; and if needed, a binder such as magnesium aluminum silicate,gelatin, methylcellulose, sodium carboxymethylcellulose, orpolyvinylpyrrolidone.

Said oral forms may be tablets coated with sucrose or with variouspolymers.

Alternatively, the tablets can be manufactured by using carriers such asacrylic and methacrylic acid polymers and copolymers; cellulosederivatives such as hydroxypropylethylcellulose; or other appropriatematerials. These materials confer a prolonged or delayed activity byprogressively releasing a predetermined quantity of fluoxetine (orpharmaceutically acceptable salt thereof) or 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (or pharmaceutically acceptablesalt or solvate thereof).

The oral formulations can also be in form of capsules allowing theextended release of fluoxetine (or a pharmaceutically acceptable salt orsolvate thereof); of 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (orpharmaceutically acceptable salt or solvate thereof); or of both theactive ingredients.

A fixed-dose combination according to the present invention may be adosage unit form consisting of a capsule comprising for examplefluoxetine hydrochloride Component (a), in an amount equivalent to 10 mgof fluoxetine base; and pramipexole dihydrochloride monohydrateComponent (b), in an amount of 6.5 mg, in admixture with apharmaceutical carrier.

Another fixed-dose combination may be formulated in tablets in whichfluoxetine hydrochloride Component (a), in an amount equivalent to 10 mgof fluoxetine base is in an IR-formulation and pramipexoledihydrochloride monohydrate, in an amount of 7.5 mg, is incontrolled-release formulation, for example as a dispersion of saidcomponent in hydroxypropyl methyl cellulose or in a film-coatedmicrogranule. Said tablet may be a tablet with two superimposed layers,or a bilayer tablet wherein pramipexole dihydrochloride dihydrate, inER-formulation is in the core and the fluoxetine, in IR-formulation, isin the outer layer. The core or both the core and the outer layer maycoated with a film. The pharmaceutical compositions may also beformulated in TTS, such as a patch formulation wherein the activeingredient or the mixture of the active ingredients may compriseadjuvants such as D-sorbitol, gelatin, kaolin, methyl paraben,polysorbate 80, propylene glycol, propyl paraben, povidone, sodiumcarboxymethylcellulose, sodium polyacrylate, tartaric acid, titaniumdioxide, and purified water. A patch formulation may also contain skinpermeability enhancer such as lactate esters (e.g., lauryl lactate),triacetin or diethylene glycol monomethyl or monoethylether.

In the above pharmaceutical compositions, the preferred fluoxetine, or apharmaceutically acceptable salt or solvate thereof, active ingredientis fluoxetine base or its hydrochloride and the preferred6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine activeingredient, or a pharmaceutically acceptable salt thereof, ispramipexole base or its dihydrochloride monohydrate.

EXAMPLE 1

A Phase I-II clinical study was conducted in parkinsonian subjectsreceiving oral doses of pramipexole or fluoxetine, alone and incombination. The trial was designed as a single-blind,placebo-controlled study.

The objective of the study was to demonstrate that pramipexole andfluoxetine, when administered together at their standard therapeuticdoses, can safely normalize concentrations of synuclein species inperipheral blood exosomes.

To be enrolled in the study, male or female participants (40 to 89 yearsof age) were required to carry the diagnosis of Parkinson's disease or arelated synucleinopathic disorder. Additionally, they had to agree torefrain from other anti-parkinsonian (excepting levodopa-carbidopa) orantidepressant drugs, and to avoid prolonged intensive physical exerciseduring the conduct of this study. All subjects signed an informedconsent form indicating that they understood the purpose of andprocedures required for the study and that they were willing toparticipate in the study and comply with all study procedures andrestrictions. Key criteria for exclusion of a subject from enrollment inthe study were as follows:

-   1. Any clinically relevant acute or chronic disease which could    interfere with the subjects' safety during the trial, expose them to    undue risk, or interfere with the study objectives.-   2. History or presence of gastrointestinal, hepatic, or renal    disease or other condition known to interfere with the absorption,    distribution, metabolism or excretion of the study medications;-   3. History of substance abuse, known drug addiction, or positive    test for drugs of abuse or alcohol.-   4. History of drug or other significant allergy.-   5. Congenital long QT syndrome; a previous history of QT    prolongation; a family history of long QT syndrome or sudden cardiac    death; and other conditions that predispose to QT prolongation and    ventricular arrhythmia-   6. Treatment with centrally active drugs except for    levodopa-carbidopa given at a stable dose for at least 3 months.-   7. Excessive daily consumption of xanthines containing drinks    (i.e. >500 mg/day of caffeine).-   8. Hospitalization or intake of an investigational drug within 30    days of study entry. Following baseline clinical and laboratory    evaluations, consenting individuals meeting accession criteria were    first randomized to either pramipexole or fluoxetine treatment. In    either case, dosage of the initial drug was gradually increased over    the ensuing 6-8 weeks in accordance with current recommendations to    each patient's maximum tolerated dose (MTD) or the maximum    recommended dose, whichever is lower, and stably maintained for    approximately 6 weeks. Patients then entered the next study phase,    lasting about 6-8 weeks when the second study medication was added    to their ongoing treatment regimen, in accordance with its    recommended titration schedules to their MTD or the maximum    recommended dose. Once safe and tolerable doses of the drug    combination were achieved, it was stably maintained for    approximately 6 weeks. Doses of both drugs were then be tapered in    accordance with current recommendations and patients were returned    to their pre-admission regimen pending discharge from the study.

Drug safety-tolerability was monitored by means of standard clinical andlaboratory tests on a weekly basis during dose titration, and otherwiseat intervals not exceeding every 4 weeks. Weekly telephone interviewswere generally conducted on those not scheduled for a clinic visit. Afinal safety check was performed approximately one month afterwithdrawal of all study medications.

Additionally, venous blood for synuclein and drug assays was collectedon the same schedule.

Results surprisingly showed that the oral administration of acombination of pramipexole and fluoxetine was associated withcharacteristic alterations in synuclein and synuclein congenerconcentrations in exosomes collected from peripheral venous bloodsamples from patients who safely tolerated their therapeutic regimens.

In conclusion, the co-administration of standard approved doses ofpramipexole and fluoxetine yielded clear peripheral evidence of adrug-combination-induced tendency to normalize synuclein processingindicative of a reduction in toxic species formation in the centralnervous system of a type associated with a neuroprotective efficacy thatclinically benefits patients suffering from Parkinson's disease or arelated synucleinopathy.

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1. A method for treating a patient suffering from a synucleinopathywhich comprises treating said patient with fluoxetine or apharmaceutically acceptable salt or solvate thereof in combination witha 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2 -amine or of apharmaceutically acceptable salt or solvate thereof.
 2. The method ofclaim 1 wherein said synucleinopathy is selected from the groupconsisting of Parkinson's disease, Lewy body disease, Alzheimer'sdisease, mutations in the glucocerebrosidase gene, and multiple systematrophy.
 3. The method of claim 1, wherein said6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine orpharmaceutically acceptable salt or solvate thereof is (S)-6-propylamino-4,5,6,7-tetrahydro- 1,3 -benzothiazole-2-aminedihydrochloride monohydrate.
 4. The method of claim 1, wherein saidfluoxetine is formulated in a pharmaceutical composition in dosage unitform comprising said fluoxetine in an amount per unit form of from 2 mgto 90 mg and said 6-propylamino-4,5,6,7-tetrahydro-1,-benzothiazole-2-amine is formulated in a pharmaceutical composition indosage unit form comprising said6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine in an amountequivalent to from 0.125 mg to 3000 mg of pramipexole dihydrochloridemonohydrate, said amount including a (S)-enantiomer amount equivalent tofrom 0.125 mg to 20 mg of pramipexole dihydrochloride monohydrate. 5.The method of claim 4, wherein said fluoxetine or pharmaceuticallyacceptable salt thereof is formulated in a pharmaceutical composition indosage unit form comprising said fluoxetine or pharmaceuticallyacceptable salt thereof in an amount per unit form of from 2 mg to 40 mgin an IR- or ER-formulation.
 6. The method of claim 4, wherein saidfluoxetine or pharmaceutically acceptable salt thereof is formulated ina pharmaceutical composition in dosage unit form comprising saidfluoxetine or pharmaceutically acceptable salt thereof in an amount perunit form of 90 mg in an ER-formulation to be administered once a week.7. The method of claim 4, wherein said fluoxetine or pharmaceuticallyacceptable salt thereof is administered at a daily dose equivalent tofrom 4 mg to 40 mg of fluoxetine base and said6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or of apharmaceutically acceptable salt or solvate thereof is administered at adaily dose equivalent to from 1.5 mg to 3000 mg of pramipexoledihydrochloride monohydrate., said daily dose including a (S)-enantiomerdaily dose equivalent to from 1.5 mg to 6 mg of pramipexoledihydrochloride monohydrate.
 8. Fluoxetine, for use for the treatment ofa synucleinopathy in combination with 6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine.
 9. The use of claim 8,wherein said synucleinopathy is selected from the group consisting ofParkinson's disease, Lewy body disease, Alzheimer's disease, mutationsin the glucocerebrosidase gene, and multiple system atrophy.
 10. The useof claim 8 wherein said 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or pharmaceutically acceptable salt or solvatethereof is (S)-6 -propylamino-4,5,6,7-tetrahydro- 1,3-benzothiazole-2-amine dihydrochloride monohydrate.
 11. The use offluoxetine for the manufacture of a medicament for the treatment of asynucleinopathy in combination with 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine.
 12. The use of fluoxetine and of6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine for themanufacture of a medicament for the treatment of a synucleinopathy, saidmedicament consisting of a pharmaceutical composition in dosage unitform comprising said fluoxetine and said6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine in admixturewith a pharmaceutical carrier or vehicle.
 13. A pharmaceuticalfixed-dose combination consisting of a pharmaceutical composition indosage unit form comprising fluoxetine or a pharmaceutically acceptablesalt or solvate thereof, as Component (a) and a6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine or apharmaceutically acceptable salt or solvate thereof, preferably withpramipexole or a pharmaceutically acceptable salt thereof, as Component(b), in admixture with a pharmaceutical carrier or vehicle
 14. Thefixed-dose combination of claim 13, wherein said composition comprises(a) fluoxetine, in an amount per unit form of from 2 mg to 90 mg; and(b) a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amineselected from the group consisting of (S)-6-propylamino-4,5,6,7-tetrahydro-1,3 -benzothiazole-2-amine or a pharmaceuticallyacceptable salts and solvates thereof, in an amount per unit formequivalent to from 0.125 mg to 20 mg of pramipexole dihydrochloridemonohydrate; (R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (the racemate) and pharmaceutically acceptablesalts and solvates thereof, in an amount per unit form equivalent tofrom 0.25 mg to 40 mg of pramipexole dihydrochloride monohydrate; and a(R)/(S)-mixture comprising6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, in an amountper unit form equivalent to from 50 mg to 3000 mg, said amount per unitform including a (S)-enantiomer amount equivalent to from 0.125 mg to 20mg and (R)- 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine,in an amount of from 50 mg to 3000 mg (minus from 0.125 mg to 20 mg).15. A fixed-dose combination consisting of a pharmaceutical compositioncomprising (a) fluoxetine, in an amount per unit form of from 2 mg to 90mg; and (b) a 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amineselected from the group consisting of(S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine or apharmaceutically acceptable salts and solvates thereof, in an amount perunit form equivalent to from 0.125 mg to 20 mg of pramipexoledihydrochloride monohydrate;(R,S)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine (theracemate) and pharmaceutically acceptable salts an solvates thereof, inan amount per unit form equivalent to from 0.25 mg to 40 mg ofpramipexole dihydrochloride monohydrate; and a (R)/(S)-mixture.comprising 6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine,in an amount per unit form equivalent to from 50 mg to 3000 mg, saidamount per unit form including a (S)-enantiomer amount equivalent tofrom 0.125 mg to 20 mg and (R)-6-propylamino-4,5,6,7-tetrahydro-1,3-benzothiazole-2-amine, in an amountof from 50 mg to 3000 mg (minus from 0.125 mg to 20 mg); in admixturewith a pharmaceutical carrier or vehicle.
 16. A fixed-dose combinationconsisting of a pharmaceutical composition comprising (a) fluoxetine ora pharmaceutically acceptable salt thereof, in an amount per unit formequivalent to from 2 mg to 90 mg of fluoxetine base; and (b) pramipexoleor a pharmaceutically acceptable salt thereof, in an amount per unitform equivalent to a range selected from the group consisting of from0.125 mg to 20 mg, from 0.125 mg to 15 mg, from 0.125 mg to 10 mg, from0.125 mg to 7.5 mg, and from 0.125 mg to 6 mg of pramipexoledihydrochloride monohydrate; in admixture with a pharmaceutical carrieror vehicle.